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Medicine and Social Justice will have periodic postings of my comments on issues related to, well, Medicine, and Social Justice, and Medicine and Social Justice. It will also look at Health, Workforce, health systems, and some national and global priorities

Friday, November 25, 2011

We recently celebrated Veteran’s Day, an opportunity to honor the men and women who have served the rest of us, putting their lives on the line, in the wars that our nation has fought. It was a numerologically special day, November 11 this year, being 11/11/11. While I have opposed almost all of the wars fought in my lifetime, as stupid and often motivated by the same greed on the part of the wealthiest that so clearly determines the behavior of our nation, I have only admiration and respect for those who put their lives on the line. The history of the world is often the history of wars, usually one more senseless than the last, and it is the history of the regular people who serve, and are killed, or wounded, or mutilated, or survive apparently intact.

Veteran’s Day began as Armistice Day, with the signing of the peace after WW I, a model for a brutal war that slaughtered millions for no good reason. I live in Kansas City, home of the nation’s WW I Museum, and it is a must-see for anyone who has not studied this first modern war, with millions soldiers dying in trenches; with the first large-scale wartime use of airplanes, with poison gas, with all the other viciousness that people were able to devise. There are some who prefer the use of name “Armistice Day” because it signifies “peace”; I am willing to celebrate our veterans without celebrating, or even condoning, the wars that took the lives of so many of their comrades.

We have not always honored veterans, and we do not do so now. “Honored” in words, sure; honored in deeds, in providing services for them to re-integrate into civilian society and find jobs, even to provide the health care that they need to treat the wounds, physical and mental, that they suffered in battle, not so much. Perhaps the most ignominious and dishonorable treatment of veterans was the attack on the “Bonus Army” of 1932. In 1924, Congress had issued “bonus certificates” to these veterans, but there was a catch – they were not redeemable until 1945. This was not of much help to the men who had “won the war” but were suffering unemployment during the depths of the Great Depression. Over 43,000 people, as many as 20,000 veterans plus members of their families, were camped in Washington DC parks, to demand payment of these bonuses. (It is of interest that President Coolidge had vetoed the bonuses in 1924 with the statement that "patriotism... bought and paid for is not patriotism," before Congress overrode his veto!) Tiring of all these dirty and ragtag families camped on public property (and, of course, the reminder that they brought of the broken promise), on July 28, 1932, President Hoover send the army to break up the encampment and rout them.

That is correct. The President of the United States sent active duty army troops, under the command of General Douglas MacArthur and assisted by Majors Dwight Eisenhower and George Patton, to attack its own veterans. You didn’t learn this in school? Maybe it wasn’t really that important. Right. It happened. From Wikipedia:

“At 4:45 p.m., commanded by Gen. Douglas MacArthur, the 12th Infantry Regiment, Fort Howard, Maryland, and the 3rd Cavalry Regiment, supported by six battle tanks commanded by Maj. George S. Patton, formed in Pennsylvania Avenue while thousands of civil service employees left work to line the street and watch. The Bonus Marchers, believing the troops were marching in their honor, cheered the troops until Patton ordered the cavalry to charge them—an action which prompted the spectators to yell, "Shame! Shame!"

After the cavalry charged, the infantry, with fixed bayonets and adamsite gas, an arsenical vomiting agent, entered the camps, evicting veterans, families, and camp followers. The veterans fled across the Anacostia River to their largest camp and President Hoover ordered the assault stopped. However Gen. MacArthur, feeling the Bonus March was a Communist attempt to overthrow the U.S. government, ignored the President and ordered a new attack. Fifty-five veterans were injured and 135 arrested….During the military operation, Major Dwight D. Eisenhower, later President of the United States, served as one of MacArthur's junior aides.Believing it wrong for the Army's highest-ranking officer to lead an action against fellow American war veterans, he strongly advised MacArthur against taking any public role: "I told that dumb son-of-a-bitch not to go down there," he said later. "I told him it was no place for the Chief of Staff." Despite his misgivings, Eisenhower later wrote the Army's official incident report which endorsed MacArthur's conduct.”

That’s right. They used poison gas on WW I veterans, many of whom were suffering the effects of gas attacks during the war. Eisenhower, who may look like the “good guy”, was mainly concerned about the seemliness of the army’s Chief of Staff (MacArthur) leading the attack on Anacostia, not the attack itself.

The country was in a Depression. The more than $3 Billion that was owed these veterans was a lot of money for the government during the Depression. Not a good reason to not pay it. Just as it is not a good reason for us to cut back benefits for veterans today, in our own “recession”. In 1930, the Veterans Administration was created, combining several “veterans’ homes” and hospitals. After WW II, when the bonus checks would have come due for the WW I veterans, the GI Bill was passed, granting veterans the opportunity to get needed benefits, including an education delayed by the war. These benefits are regularly eroded by Congressmen who give fine speeches on November 11, but care as much about the actual people who fought our wars as much as Presidents Hoover and Coolidge did. In fact, President Coolidge’s statement about “patriotism” justifying not paying the bonuses would never be uttered by a current-day politician, but the actions of the Congress, which overrode the veto, would not either. We do not have enough money in the US, the story goes. We need to work down the deficit. By taking the money from the most needy, from the poor and the working class and the middle class, including our veterans; certainly not from the wealthiest.

The deficit was created by politicians doing the bidding of the <0.1% of the population who control most of our wealth, cutting their taxes to increase their wealth. And, oh yes, fighting two wars in Iraq and Afghanistan, killing and maiming and creating new veterans who can barely get the help that they need. And, of course, insuring that the 0.1% have every dollar of ours that they lost for us replaced – to them, not us, we pay the bill – and more, is far more important than providing health services and education and jobs for the veterans, or for anyone else.

We would (I think) not send the Army to attack a veterans’ encampment today, but who knows? The people who had fought WW I were honored by our people in those days as heroes even as much or more than our current veterans, and yet our President sent the Army to attack them with cavalry, tanks, and poison gas. Recent history shows us there is no depth of calumny and duplicity to which defenders of the status quo will not go to achieve their ends; remember the military history of #1 hawk Richard Cheney (he had none; he was doing “more important” things during the Vietnam war). Remember the defeat of Senator Max Cleland of Georgia by an opponent who questioned his patriotism and toughness because the Senator had raised questions about the war in Iraq? Sen. Cleland was a decorated Vietnam veteran who had lost both legs and an arm in that war; his opponent had not served.

And, unlike after WW I or WW II, without a draft, with a large group of young people who can find no other jobs, most of us are no longer involved in paying the human price of war. This is the focus of As Fewer Americans Serve, Growing Gap Is Found Between Civilians and Military by Sabrina Tavernise in the NY Times, November 25, 2011. “`What we have is an armed services that’s at war and a public that’s not very engaged’ said Paul Taylor, executive vice president of the Pew Research Center. `Typically when our nation is at war, it’s a front-burner issue for the public. But with these post-9/11 wars, which are now past the 10-year mark, the public has been paying less and less attention.’”

This separation means that, while politicians laud their service on Veterans’ Day, the actual veterans, after serving and suffering from real wounds both physical and mental, are returning to a society that has no jobs, and is investing less and less in their care. What we need to see is more action on behalf of veterans, and on behalf of the American people. Instead, what we see from too many of our hypocritical Congressmen and “leaders” who sing the praises of our veterans while cutting their benefits, are actions that would make Calvin Coolidge proud.

Tuesday, November 15, 2011

In Seeking a Cure for Troubled Hospitals in Brooklyn, NY Times, November 10, 2011, Nina Bernstein reports on the challenges faced by not-for-profit hospitals in that part of New York City. In 1980, she notes, Brooklyn had 26 hospitals, while now it has 15. It has 41% fewer acute-care beds, with a ratio of 2.1/1000 people (national average: 2.6, NY State 3.1, Manhattan 4.7). Five of the largest remaining hospitals are in danger of closing; these hospitals account for 83,000 admissions, 325,000 emergency room visits, and 760,000 clinic visits per year. There is no way, the article makes clear, that the 3 public (2 city and 1 state) hospitals in the borough can come close to making up this deficit should those hospitals close. But they may, because they are running in the red, and there is no reason to think that, even if President Obama’s Health Reform stays intact, this will change. They largely care for Medicaid patients, and Medicaid both doesn’t pay enough to cover a hospital’s costs, and is targeted for cuts because it accounts for such a large portion of state budgets.

The reason is that these hospitals care for poor people, as the original title of the article in the Times’ print edition, “Brooklyn’s ailing hospitals and care for the poor”, made clear. The problem, however, is not unique to Brooklyn; it confronts hospitals all over the country. “Brooklyn shows the acute stage of a problem that has vexed the nation for years: how to sustain delivery of major medical care to the poor.” Even more, the fact that increasing portions of the population are uninsured or poorly insured, and that the focus in of the federal deficit reduction process is to further cut payments for Medicare as well as Medicaid, the trend is likely to continue and to increase. From the point of view of hospitals, the issue is whether they will survive or not survive, largely dependent upon where they are located and their ability to attract the decreasing number of well-insured patients. While those who run successful hospitals like to congratulate themselves on being such good managers, the article notes the observations of Alan Sager of Boston University, a long-time student of hospital closings across the country, that “what best predicted that a hospital would be closed was not inefficiency, but location in a minority neighborhood.”

This is not at all surprising; indeed, it tracks with everything else that has been going on in our society: services for the most needy are cut back and ultimately disappear, while services for the least needy get more and more available, marketed, extensive (and expensive) as providers of those service seek to make themselves attractive to a shrinking, privileged market. The problem is that for this to be OK, one has to accept the idea that healthcare access should be determined by the market, rather than that they should be available for everyone in the society. This means that hospitals will close, and providers will not practice, in areas that have high concentrations of people who are poor, uninsured, underinsured, and members of minority groups. But those hospitals that do survive, in higher-income neighborhoods, will compete in the areas that are high-profit “product lines” so that they, and not their competitors, will attract that market segment. Such product lines can include elective and cosmetic surgery, but they also include areas such as heart disease and cancer care because payers (driven by the federal payer, Medicare) reimburse hospitals at rates far above their costs for providing care for these conditions, but not for others. Thus, capacity is overbuilt, resulting in greater capacity (for example, for cancer treatment for the insured) than is needed for the population because each hospital wants to be the one who makes the big markup on chemotherapy drugs.

But, of course, there is much less access to care for the same conditions for people without insurance, or even for those whose conditions are not in the “high profit” group. And the lack of access to preventive care, to primary care, to care of conditions in their more treatable stages, means that the people who enter the “ailing hospitals” of Brooklyn or elsewhere, are farther along in their diseases and more expensive to treat, so that caring for them drives the hospitals deeper into debt. And this creates a downward spiral. For a patient described in the article “Surgery revealed a strangulated hernia so far gone that cutting out life-threatening infected tissue left an open wound…but before Mr. Hutchins could be released, the hospital had to get him a portable wound pump. At hospitals that pay suppliers promptly, administrators say, the device typically gets same-day delivery. At Wyckoff, it took a week.” And, since “…last year, Medicaid cut by 31 percent what it would pay for a case like his,” the hospital loses even more money providing his care for an extra week.

In poor neighborhoods, almost all services have more limited availability. This may make sense, say, for upscale restaurants, or clothing stores. It is much more problematic when those communities do not have food stores. Or healthcare. It is, however, the result of applying a competitive market model to healthcare, leading to overcapacity for a portion of the population and a deficit or absence of care for another part of the population (based on wealth, location, and type of condition). This is why most other countries with the resources have made the decision to provide access to health care to all their people, rather than ration based on the market, which by definition leaves out the people at the bottom who cannot pay. Our healthcare nonsystem reinforces these inequities, which are more than unfair, they sap the ability of our country to have a healthy and productive workforce.

There are solutions, but not the ones being suggested by some for Brooklyn (“…expunge the hospitals’ debt of more than $1 billion, partly at taxpayer expense, and then let large for-profit companies take over the facilities and restructure patients’ care,” which sounds an awful lot like “bail out the bankers and financiers with public funds”. The solutions are to create a national health system, a system which guarantees healthcare access for everyone. Most cost effectively, a single-payer system. It can be done, for not much more than we now spend, because of the excess waste and profit built into our reimbursement methodology. It can be driven by the federal government because the federal government is the largest payer for health care.

In an article on the reopening of the national physician database (After protests, national doctor database reopens — with a catch), Alan Bavley of the Kansas City Star quotes Senator Chuck Grassley, an Iowa Republican, as saying “This agency needs to remember that half of all health care dollars in the United States comes from taxpayers, so the interpretation of the law ought to be for public benefit.” That half of all healthcare dollars is as much, on a per-capita basis, as most other OECD countries spend altogether, and it is what drives reimbursement (for cancer chemotherapy or diabetes or asthma) in this country. It would be great if Sen. Grassley would take the lead in ensuring that not only the physician database, but all of healthcare services provided with dollars from taxpayers, is “for public benefit” and not private profit.

The general counsel for one of the threatened Brooklyn hospitals is quoted by Bernstein as saying “We stay open at the grace and generosity of our vendors.They know it will eventually get better, because we have to have hospitals. Otherwise, we’ll have sick and dying people lying in the streets, and nobody wants that.” But the solution is not just to patch up Brooklyn’s, or anywhere else’s, acute problems; it is to fix the broken system and perverted incentives.

Tuesday, November 8, 2011

“Sports medicine said to overuse MRIs”, by NY Times health reporter Gina Kolata, October 29, 2011, begins by reporting on an unpublished (as far as I can tell) study by an orthopedic sports medicine physician from Florida, Dr. James Andrews, who scanned the shoulders of 31 asymptomatic, uninjured professional baseball pitchers and found that all were read as “abnormal”. The article goes on to quote a long list of leading sports medicine physicians who find fault with the overuse of MRI scans in both professional and casual athletes. They are particularly concerned that doctors substitute the readings of these scans for history and physical examination and professional judgment. One problem is, according to Dr. Bruce Sangeorzan from the University of Washington, is that the MRI “...is a very sensitive tool, but it is not very specific.” Sensitivity and specificity are terms that refer to the characteristics of a test. The more sensitive a test, the more likely it is to find something that is actually wrong; the more specific the test, the more likely it is to be normal when there is not actually something wrong. Dr. Sangeorzan’s point is that the MRI scan is likely to be abnormal even when there is no actual problem with the person.

This assessment is echoed by most of the physicians interviewed. “‘It is very rare for an MRI to come back with the words “normal study,”’ said Dr. Christopher DiGiovanni, a professor of orthopedics and a sports medicine specialist at Brown University. ‘I can’t tell you the last time I’ve seen it.’” The article profiles a person who injured his knee skiing and had two different doctors tell him that the MRI (ordered even before he was examined) indicated he had a torn anterior cruciate ligament (ACL) and needed surgery. Another orthopedic surgeon, Dr. Freddie H. Fu of the University of Pittsburgh, found he had no tear using a more sensitive MRI – which he ordered because, after seeing the patient, his story and exam was inconsistent with a torn ACL: “He could never have continued skiing with a torn A.C.L. The diagnosis ‘made no sense,’ Dr. Fu said.”

Such overdiagnosis can lead to excess surgery, with all the concomitant risks of these procedures. One concern is the financial conflict of interest that can exist. The physician who reads the MRI gets paid a fair amount, and the owner of the machine (which may be a hospital or a physician or group of physicians, either radiologists or orthopedists) get paid even more for doing the scan. And, if there is surgery, both the surgeon and the facility (hospital or outpatient surgicenter) where it is done make money. The other issue is that both doctors and patients believe that technology is “better” in most cases, and want both a definitive diagnosis and treatment. The danger, of course, is that the diagnosis may wrong and/or the treatment unnecessary.

Many of us have been told by a car mechanic that we needed a repair (new brakes, transmission, valve job), a diagnosis often made with the assistance of computer technology. Sometimes we have brought the car to another mechanic to have the diagnosis confirmed, and sometimes been told that the procedure was not necessary. Then we get angry and believe the first mechanic was a “thief”, out to make money. The reality is, however, that even if they are, all it costs is money; the car may not have needed new brakes quite yet, but the new brakes are not going to harm it. The same is not true for surgical intervention on a knee or shoulder or any other part of the body. Replacing the parts of a human-constructed car is different from cutting into and replacing the parts of a person. While both can have complications from being done badly, surgery on a person can have complications even when done right.

The counterpoints to this article are in the same issue of the NY Times. They area series of letters addressing “The debate over routine mammograms”, which evidence the fascination that the public has with “making a diagnosis”. Some were written by representatives of advocacy organizations, who repeat the idea that saving a life is worth any cost; “The $5 billion spent annually on mammography screening is worth it to the women who are saved,”, one of these letters declares. This argument is flawed on many levels. Sure, if I am “saved” by having had a mammogram (putting aside, for the moment, any other questions of false-positive tests, treatment options, etc., and assuming the mammogram alone is the reason for my salvation), I am pleased. But $5 billion? Could we have done it for $2.5 billion? Or could we do a better job for $10 billion? Am I unhappy because I had a negative mammogram but the money spent on doing these tests meant that it wasn’t spent on treatments for something I do have, perhaps diabetes, or drug addiction, or for prevention through prenatal care or efforts to ban indoor smoking?

The US Preventive Services Task Force (USPSTF) recommends routine mammogram screening (“screening” means in women who are asymptomatic, and does not include those who have had previous cancer or abnormal mammograms or lumps or bleeding, etc.) every two years. In my hospital, we are trying to set the criteria by which our electronic medical record will remind us to do screening. Initially, we decided to use USPSTF guidelines. But now some physicians are saying that they think we should order mammograms yearly. Oh. If we are not going to use the recommendations based upon the most thorough use of the existing data, why yearly? Why not every six months? Every week?

Well, in part it is cost. To screen every woman every week would cost a lot. But it would also be inconvenient for those women. And there are, in addition to complications of treatment, results of questionable screening tests to further define what is going on, and these add more costs, discomfort, uncertainty, and risk. I have discussed these issues, with particular emphasis on another screening test that the USPSTF has recommended against using at all, the PSA test for prostate cancer, in recent blogs, most recently PSA redux: The USPSTF finally recommends NOT getting it!, October 14, 2011. For mammography, if less frequent routine screening of everyone with targeted screening of individuals who are at high risk, can have the same positive results without the high costs, both financial and in terms of risk to people, that is a better strategy.

Most important, however, is that arguments such as “The $5 billion spent annually on mammography screening is worth it to the women who are saved,” pretends that such spending occurs in a bubble. There is limited money, and it is getting more limited since the financial crisis and is likely to get worse with the “cut, cut, cut” attitude toward programs for the most vulnerable being the apparent mantra in both Congress and the states. Even in the best times for the economy, there were millions of people not getting the most basic health care, not getting well-established screening tests done, not getting treatments that were proven effective for conditions that they had (and maybe didn’t know they had) because they didn’t have access – insurance, geographic access, access from the perspective of cultural, language and health literacy, whether they were “legal” or many other factors. As these cuts increase, those millions are joined by millions, tens of millions, more. Access for everyone to proven effective interventions must be a priority over access for some to possibly effective interventions, and certainly over access for anyone to those where the danger exceed potential benefit.

The very same issue of the NY Times contains a column by Charles Blow, “America’s exploding pipe dream”, in which his words-to-table ratio is even less than usual, emphasizing the data in the table he attaches. But here are some important words: "We have not taken care of the least among us. We have allowed a revolting level of income inequality to develop. We have watched as millions of our fellow countrymen have fallen into poverty. And we have done a poor job of educating our children and now threaten to leave them a country that is a shell of its former self. We should be ashamed." Clearing up that shame, taking care of the “least among us”, should be our watchword.

Some of the most important work in the area of social determinants of health has been done by the British physician and epidemiologist Sir Michael Marmot, whose “Whitehall” studies, begun decades ago, showed that health status was associated with socioeconomic class. He has continued this with his recent work “Fair Society, Health Lives”[1]. Thus, it should not come as a surprise that it was under Dr. Marmot’s recently-completed tenure as President that the British Medical Association (BMA) issued its report “Social Determinants of Health: What Doctors Can Do”, in October 2011. It is more interesting that Dr. Marmot, in his introduction to the report, notes that “ … as I mentioned in my presidency acceptance speech, I was surprised at being approached to be president at all,” because “My work has been focused on inequalities in health where I have emphasised the circumstances in which people are born, grow, live, work, and age rather than anything specifically to do with health care provision. I have emphasised not just the causes of health inequalities—behaviours, biological risk factors—but the causes of the causes. The causes of the causes reside in the social and economic arrangements of society: the social determinants of health. More than that though more recently my work has looked at what can be done to address these issues across the life-course.”

Many of us in medicine, even on this side of the Atlantic, were thrilled that the BMA had chosen Dr. Marmot as its president precisely for these reasons. The current report shows that this was well-placed enthusiasm, for it marks a the commitment of the BMA to improving the health of the British population even, and perhaps especially, when that requires physicians to work outside of their “usual” venues. That is, when the work requires collaboration with other professionals, particularly educators but also social service agencies, to be effective. And to exercise their roles as community leaders, not simply purveyors of drugs, operations, and individual advice: “We recognise that not every doctor has the opportunity to change the social determinants of health throughout the life course of individual patients and have thus included other ways in which they can make a difference, as doctors working as community leaders.”

“Social Determinants of Health: What Doctors Can Do” presents conceptual models and large-scale goals, as well as principled statements of how physicians must act to create conditions of social justice and reduce the gradient of health disparity that results from different life circumstance. For example, it takes from “Fair Society, Healthy Lives” the following set of policy objectives that physicians and their organizations should work towards:

A - Give every child the best start in life

B - Enable all children, young people and adults to maximise their capabilities and have

control over their lives

C - Create fair employment and good work for all

D - Ensure healthy standard of living for all

E - Create and develop healthy and sustainable places and communities

F - Strengthen the role and impact of ill health prevention

(These are expanded upon in “Annex A”, beginning on p. 26)

However, the paper goes beyond these generalities and provides specific examples of programs that have been and are in place in different communities across Britain that have made an impact on these areas. The BMA commits that they “will keep examples of effective actions on our website, and encourage the World Medical Association to garner international examples, to aid doctors seeking ways to make a difference.” One example of this two-phased approach of identifying the problems and seeking examples of solution is in “The Health Impacts of Cold Homes and Fuel Poverty report”, whose main findings of direct impacts included:

- Investing in the energy efficiency of housing can help stimulate the labour market and economy, as well as creating opportunities for skilling up the construction workforce.”

They then describe a program in Manchester that is working to addresses this problem.

Another intervention is occurring in an impoverished part of England, where the “Bromley-by-Bow Centre aims to serve the local community by providing a wide range ofservices and activities, which are integrated and co-operative in nature. They host the local GP surgery, a variety of social enterprises, a children’s centre, artists’ studios, a healthy living centre, and provide adult education courses, care and health services for vulnerable adults, outreach programmes and a range of advice services. This approach enables GPs to refer patients to services that help to tackle the social determinants of ill health, including welfare, employment, housing and debt advice services.”

A society can never achieve a significant improvement in health, or decrease health disparities, unless it consciously and forthrightly addresses the social determinants of health. Physicians can be leaders in this effort, or they can sit comfortably in their offices and hospitals tending to the individual health problems of people that could have been prevented before. Dr. Marmot says

“During my tenure I have been struck, but not surprised, by members’ utter commitment to

improving the health, not just of individual patients, but of society as a whole….As the year progressed I could see more and more how my tenure at the BMA and my work on the social determinants of health were a perfect fit. Time after time I was faced with examples where doctors were working tirelessly to increase fairness and social justice by acting on the social determinants of health to reduce health inequalities.”

That makes me proud of my colleagues in Britain and in the BMA, but these are also characteristics of many doctors in the US. And of many medical students, who are driven by their desire to make a difference. The US is not the UK (we don’t, for one really big example, have a national health service or even a national health insurance program!), but we have real needs and real caring people, including physicians. We just need to keep focused on health and how to improve it and not be dissuaded by tangential issues. We need to maintain the energy and idealism of medical students and ensure that it grows, rather than withers, thoughout their careers.